RHC Health Check Form

RHC ONLINE HEALTH INTAKE FORM

Complete this form for supplement ordering inquiries. It will take about 5 minutes.
The following questionnaire will provide us information regarding your health and allow us to determine if there are possible contraindications to requested and/or recommended natural products. This information will not be used for marketing or shared with anyone. Please review our Privacy Policy.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleNon-Binary
E-mail*
Phone Number*

Area CodePhone Number

Next: Diet and Lifestyle
Do you exercise?*

Never1-2 times a week3-4 times a week5-6 times a weekEveryday
Please list the types of exercise you do regularly
Do you smoke?*
How many per wk?
Do you take recreational drugs?
Please list any food allergies / intolerances that you are aware of?
How many ounces of water do you drink per day?*
Do you drink alcohol?

YesNo
How many servings per week?*

RHC ONLINE HEALTH INTAKE FORM